Perioperative Evaluation and Management

  • T. Joseph McKenna
Chapter

Abstract

While the investigative procedures leading to a diagnosis of Cushing’s syndrome and to identification of the precise disorder giving rise to the syndrome and the nature and technical details of the therapeutic interventions are well described, the perioperative management and intermediate follow up to surgical intervention are less well established. In this chapter that portion of the pre-operative assessment which bears particularly on the post-operative management will be considered. In the immediate post-operative period the need for glucocorticoid replacement will be considered. Fundamental to this will be an assessment as to whether or not a cure has been achieved. It is useful at this time to compare pre-operative and post-operative pituitary function other than that involving the hypothalamic-pituitary-adrenal axis (HPAA). Where the HPAA is found to be suppressed, which almost always accompanies successful operative intervention, assessment of subsequent recovery will be needed. When there is failure of the operative procedure to affect a cure consideration will be given to additional treatment. Furthermore, although treatment may be effective for months or years in follow-up, recurrence is seen in some patients. Emphasis will be placed on management difficulties not infrequently encountered in patients in whom Cushing’s syndrome has been effectively treated who develop “the steroid withdrawal syndrome”.

Keywords

Plasma Cortisol Diabetes Insipidus Corticotrophin Release Factor Withdrawal Syndrome Plasma Cortisol Level 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
This is a preview of subscription content, log in to check access.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Iannacone, A., Gabrilove, J.L., Sohval A.R., Soffer LJ. (1959). The ovaries in Cushing’s syndrome. New Eng J Med. 261, 775–80.CrossRefGoogle Scholar
  2. 2.
    Luton, J.P., Thieblot P., Valcke J-C., Mahoudeau, J.A., Bricaire H. (1997). Reversible gonadotropin deficiency in male Cushing’s disease. J Chin Endocrinol Metab 45, 488–495.CrossRefGoogle Scholar
  3. 3.
    Sakakura, M., Takebe, K.V. Nakagawa S. (1975). Inhibition of lutenizing hormone secretion induced by synthetic LRH with long-term treatment with glucocorticoid s in hwnan subjects. J Clin Endocrinol Metab 40, 774–9PubMedCrossRefGoogle Scholar
  4. 4.
    Cunninghain, S.K., McKenna, T. J. (1994). The dissociation of adrenal androgens and cortisol secretion in Cushing’s syndrome. Clin Endocrinol 41, 795–850.CrossRefGoogle Scholar
  5. 5.
    Adler, R. A., Rosen, C. J. (1994). Glucocorticoids and osteoporosis. Endocrinol Metab Clin NAmer 23, 641–54.Google Scholar
  6. 6.
    Di Somma, C; Coloa, A., Pivonello, R., Klain M., Faggianno, A., Tripodi, F. S., Merola, B., Salvatore, M., Lombardi, G. (1998). Effectiveness of chronic treatment with alendronate in the osteoporosis of Cushmg’s disease. Clin Endocrinol 48, 655–62.CrossRefGoogle Scholar
  7. 7.
    Hermus, A. B. R., Smals, A. G., Swinkels, L. M., Huymans, D. A., Peters, G. F., Sweep, F., Corstens, F. H., Kloppenborg, P. W. (1995). Bone mineral density and bone turnover before and after cure of Cushing’s syndrome. J Clin Endocrinol Metab 80, 2859–65.PubMedCrossRefGoogle Scholar
  8. 8.
    Allen, D. B. (1996) Growth suppression by glucocorticoid therapy. Endocrinol Metab Clin N Amer 25, 699–717.CrossRefGoogle Scholar
  9. 9.
    Chrisoulidou, A., Kousta, E., Beschyah, S. A., Robinson, S., Johnson, D. G. (1998). How much, and by what mechanisms, does growth hormone replacement improve the quality of life in growth hormone deficient adults? Bailliere’s Clin Endocrinol Metab 12, 261–79CrossRefGoogle Scholar
  10. 10.
    Carroll, P. B., Christ, E. R., Bengtsson, B. A., Carlsson, L., Cristiansen, J. E. S., Clemmons, D., Hintz, R., Ho, K., Laron, Z., Sizonenko, P., Sonksen, P. H., Tanaka, T. Thorner, M (1998). Growth hormone deficiency in adult and the effects of growth hormone replacement: A review. J Clin Endocrinol Metab 83, 382–95.PubMedCrossRefGoogle Scholar
  11. 11.
    Danese, R.D., Aron, D.C. (1994). Cushing’s syndrome and hypertension. Endocrinol Metab Clin Amer 23, 299–324.Google Scholar
  12. 12.
    Nestler, J. E., McClahahan, M. A. (1992) Diabetes and adrenal disease. Balliere’s Clin Endocrinol Metab 6, 829–47.CrossRefGoogle Scholar
  13. 13.
    Williams, D.E., Shopra, I.J., Orgiazzi, J., et al. (1975) Acute affects of corticosteroids on thyroid activity in Graves’ disease. J Clin Endocrinol Metab 41, 354–61.PubMedCrossRefGoogle Scholar
  14. 14.
    Robertson, G. L. (1995). Diabetes insipidus. Endocrinol Metab Clin N Amer 24, 549–72.Google Scholar
  15. 15.
    Miller, J.W., Crapo, L. (1993). The medical treatment of Cushing’s syndrome. Endocr Rev 14, 443–58.PubMedGoogle Scholar
  16. 16.
    Trainer, P.J., Lawrie, H.S., Verheist, J. et al (1993). Transsphenoidal resection in Cushing’s disease: Undectable serum cortisol as the definition of successful treatment. Clin Endocrinol 38, 73–78.CrossRefGoogle Scholar
  17. 17.
    McCance, D.R., Besser, M., Atkinson, A. B. (1996). Assessment of cure after transsphenoidal surgery for Cushing’s disease. Clin Endocrinol 44 1–6.CrossRefGoogle Scholar
  18. 18.
    Hout, W. M., Arafah, B. M., Salazar, R., Selman, W. (1988). Evaluation of the hypothalamic-pitultary-adrenal axis immediately after adenomectomy: Is perioperative steroid therapy necessary? J Clin Endocrinol Metab 66. 1280–12.CrossRefGoogle Scholar
  19. 19.
    Estanean, V., Loughlin, T., Nergey, A. L., Zawadzki, J. K., Boothe, J. D., Winterer, J. C., Loriaux, D. L. (1991). Daily cortisol production rate in man determined by stable isotope dilution/mass spectrometry. J. Clin Endocrinol Metab 72, 39–45.CrossRefGoogle Scholar
  20. 20.
    Streeten, D. H. P., Anderson, Jr., G. J. H., Bonaventura, M. M. (1996). The potential for serious consequences from misinterpreting nornal responses to the rapid adrenocorticotrophin test. J Clin Endocrino Metab 81, 285–90.CrossRefGoogle Scholar
  21. 21.
    Mukherjee, J. J., de Castro, J., Kaltasas G., Afshar, F., Grossman, A. B., Wass, J. A. H., Besser, G. M. (1997). A comparison of the insulin tolerance/glucagon test with the short ACTH stimulation test in the assessment in the hypothalamic-pituitary-adrenal axis in the early post-operative period after hypophysectomy. Clin Endocrinol 47, 51–60.CrossRefGoogle Scholar
  22. 22.
    Oelkers, W. (1998). The role of high-and-low dose corticotropin tests in the diagnosis of secondary adrenal insufficiency. Europ J Endocrinol 139, 567–70.CrossRefGoogle Scholar
  23. 23.
    Streeten D. H. P. (1999). Shortcomings in the low dose (1 μg) ACTH test for the diagnosis of ACTH deficiency states. J Clin Endocrinol Metab 84, 835–37.PubMedCrossRefGoogle Scholar
  24. 24.
    Abdu, T. A. M., Elhaeld, T. A., Neary, E. R., Clayton, R. N. (1999). Comparison of the low dose short Synaethen test (1 μg), the conventional dose short Synacthen test (250 μg) and the insulin tolerance test for assessment for the hypothalanlic-pituitary-adrenal axis in patients with pituitary disease. J Clin Endocrinol Metab 84, 838–43.PubMedCrossRefGoogle Scholar
  25. 25.
    van Aken, M. O., de Herder, W. W., van der Lely, A. J., de Jong, F. H., Lainberts, S. W. (1997). Post-Terative metyrapone test in the early assessment of outcome of pituitary surgery for Cushing’s disease. Clin Endocrinol 47, 149–9.Google Scholar
  26. 26.
    Auchus, H. J., Shewbridge, R. K., Sheperd, M. D. (1997). “Which patients benefit from provocative adrenal testing after transsphenoidal pituitary surgery? Clin Endocrinol 46, 217.CrossRefGoogle Scholar
  27. 27.
    Bunoncore, C.M., Robinson, A.G., (1993). The diagnosis and management of diabetes insipidus during medical emergencies. Endocrinol Metab Clin N Amer 22, 411–23.Google Scholar
  28. 28.
    Hurel, S.J., Thompson, CJ., Watson, M.J., Herris, M.M., Baylis, P.H., Kendall-Taylor, P. (1996). The short Synacthen and insulin stress tests in the assessment of hypothalamic pituitaiy-adrenal axis. Clin Endocrinol 44, 144–46.CrossRefGoogle Scholar
  29. 29.
    Soule, S., Fahie-Wilson, M., Tomlinson, S. (1996). The failure of the short ACTH test to unequivocally diagnose long-standmg symptomatic secondary hypoadrenalism. Clm Endocrinol 44, 137–40.CrossRefGoogle Scholar
  30. 30.
    Shah A., Stanhope, R., Mathew, D. (1992). Hazards of pharmacological tests of growth hormone secretion in children. Brit Med J 304, 173-PubMedCrossRefGoogle Scholar
  31. 31.
    Fiad, T.M., Kirby, J., Cunningham, S.K., McKenna, T.J. The overnight single-dose metyrapone test is a simple and reliable index of the hypothalamic-pituitary-adrenal axis. Clin Endocrinol. 40: 603–609, 1994.CrossRefGoogle Scholar
  32. 32.
    Avgerinson, P. C., Chrousos, G. P., Nieman, L. K., Oldfield, E. H., Loriaux, D. L., Cutler, G. B. (1987). The corticotrophin-releasing hormone test in post-operative evaluation of patients with Cushing’s syndrome. J Clin Endocrinol Metab 65, 906–13.CrossRefGoogle Scholar
  33. 33.
    Schrell, U., Fahlbusch, R., Buchfelder, M., Liedl, S., Stalla, G. K., Muller, O.A. (1987). Corticotrophin-releasmg honuone stimulation test before and after transsphenoidal selective microadenomectomy m 30 patients with Cushing’s disease. J Clin Endocrinol Metab 64,1150–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Gellner, R., Stange, M., Schiemann, U., Domschke, W., Rengst K. (1999). CRH test prior to discontinuation of long-term low-dose glueocorticoid therapy. Exp E Clin Endocrinol Diabetes 107, 561–7CrossRefGoogle Scholar
  35. 35.
    Dixon, R.B. Christy, N.P. (1980). On the various forms of glucocorticoid withdrawal syndrome Amer J Med 68, 224–301PubMedCrossRefGoogle Scholar
  36. 36.
    Gotch, P.M. (1994). Cushing’s syndrome from the patient’s perspective. Endocrinol Metab Clin N Amer 23, 607–17.Google Scholar
  37. 37.
    Knappe, U. J., Ludecke, D.K. (1996). Persistent and recurrent hypercortisolism after transsphenoidal surgery for Cushing’s disease. Acta Neurochir (suppl) 65, 31–4.Google Scholar
  38. 38.
    Estrada, J., Boronat, M., Mielgo, M., Magallon, R., Milian, I., Diez, S., Lucas, T., Barcelo, B. (1997). The long-term outcome of pituitary irradiation after unsuccessful transsphenoidal surgery in Cushing’s disease. N Eng J Med 336, 172–7.CrossRefGoogle Scholar
  39. 39.
    Nagesser, S. K., van Seters, A. P., Kievit, J., Hennans, J., Krans, H. M., van de Velde, C. J. (2000). Long term results of total adrenalectomy for Cushing’s disease. World J Surg 24, 108–13.PubMedCrossRefGoogle Scholar
  40. 40.
    Young, W.F. (1998). Laparoscopic adrenalectomy: An endocrinologist’s perspective. Curr Opin Endocrinol Diab 6, 199–203.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2002

Authors and Affiliations

  • T. Joseph McKenna
    • 1
  1. 1.St. Vincent’s University HospitalUniversity CollegeDublinUK

Personalised recommendations